Alopecia

Loss of hair is termed effluvium, and the resulting condition is alopecia. Alopecia is characterized as scarring (cicatricial) or non-scarring; non-scarring alopecia is the more common form. It is differentiated from scarring alopecia by the absence of visible inflammation of the involved skin. Scarring alopecias are caused by several dermatological conditions that also affect glabrous (non-hairy) skin. Scarring hair loss is often very difficult to diagnose correctly and is a challenge to manage. Be sure to rule out neoplastic and autoimmune processes.

Differential Diagnosis

Non-scarring alopecia

• Acne keloidalis
  –Hypertrophic scars are characteristic
  –Often in black men at the nape of the neck
  after a chronic papulopustular eruption
• Pseudopelade of Brocq
  –Primary or end stage of inflammatory diseases (e.g., lichen planus, SLE)
  –Presents with smooth, shiny, hairless scalp patches with absent hair follicles

Workup and Diagnosis

• History and physical examination
  –Note history of the hair loss (duration, tenderness, pruritus), past medical history (e.g., lupus, sarcoidosis, internal malignancies), and medications
  –Evaluate for presence or absence of scarring (loss of hair follicles, ablation of the follicular orifice), hair loss elsewhere on the body (lichen planopilaris, some autoimmune diseases, and some lymphomas may manifest with scarring alopecia not limited to the scalp), and rashes or plaques on any part of the body (e.g., scleroderma and sarcoidosis often have skin findings beyond the scalp)
  –Subcutaneous masses, bogginess of the scalp, and cervical lymphadenopathy may suggest infection

• Trichogram (forcible hair pluck) to evaluate hair phase [normally, 80–90% of hairs are in anagen (growth, translucent hair shaft, and deeply pigmented matrix) phase; in androgenetic alopecia and telogen effluvium, telogen (resting, large bulb, transparent hair shaft) hairs are increased]
• Perform a 4 mm punch biopsy of a hairless area; if there is any redness or scale, include that area in the biopsy so that the primary pathologic process can be examined
• Labs may include free and total testosterone, DHEA-S, prolactin, thyroid function tests, iron studies, RPR, ANA, ESR
• Obtain viral and bacterial cultures of any pustules

Treatment

• Once an area of scarring alopecia has developed, no hair will ever regrow in that area; the goal of treatment is to make the diagnosis and treat to avoid further hair loss
• Wigs and/or hair transplants (punch grafts of follicles from androgen-insensitive areas to androgen-sensitive bald areas)
• Androgenetic alopecia: Oral finasteride is currently approved for men only; visible results take 3–4 months; topical minoxidil provides moderate growth within 4–12 months; in women, use antiandrogens (e.g., spironolactone, cimetidine, flutamide) if adrenal androgens are increased
• Telogen effluvium: Reassure that recovery is the norm
• Anagen effluvium: Withdraw drug or treat illness
• Alopecia areata: Superpotent steroids, intralesional steroid injections, cyclosporine, glucocorticoids, PUVA
• Tinea capitus/kerion: Oral antifungals
• Treat the inciting causes of scarring alopecia (e.g., folliculitis, lupus; prevent ingrown follicles)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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